Building the ACO

By Jim Frederick

New, holistic models for integrated, patient-centered care are emerging from the fog of health reform almost as fast as you can say “accountable care organization.” But pharmacy and retail clinic operators aren’t waiting for ACOs to fully ripen; they’re forging new alliances with hospital-based health systems and building the kind of continuity-of-care networks that could be a template for the new era of evidence-based medicine and improved patient outcomes.

If anything going on in health care traces the changes that are transforming the health system — attacking the unsustainable cost curve and dramatically improving patients’ access to care — it’s the accelerating growth of partnerships between hospital-based health systems and retail pharmacies and pharmacy-centered clinics.

It makes perfect sense. Both community pharmacies and the roughly 1,400 in-store clinics now open are evolving quickly beyond their traditional practice models with a broader menu of health-and-wellness services.

That makes them ideal extensions of hospital-based care, providing cheaper and more accessible points of entry into a local or regional health system for patients in need of basic diagnostic services and front-line care.

Boehringer Ingelheim Pharmaceuticals noted in a report on retail clinics: “The demand for health care is steadily growing as the population ages and increases, creating some strain on often overworked hospitals and physician practices.”

Retail clinics, BI noted, provide “a way of addressing this issue.”

Community pharmacists can play an equally critical role. With more and more chains and independents giving pharmacists the tools and training to practice “at the top of their license,” pharmacies allied with hospitals provide a slew of services that improve patients’ long-term health and reduce readmission rates — including preventive health services, disease management and monitoring, screenings, medication therapy management, counseling and adherence programs.

In a report in the online publication Payers & Providers, Jim Lott, EVP of the Hospital Association of Southern California, called such alliances “another primary care doorway or channel to commercial and government-sponsored ACOs with which many hospitals will be aligned.”

For hospitals, allying with local pharmacies and walk-in clinics offers clear benefits. It extends a health system’s relationships with patients and care networks, expanding access to its full range of health services. And such partnerships provide true continuity of care and follow-up for patients after they’ve been discharged.

Not least, partnerships between hospital-driven health systems and local pharmacists and clinicians provide a more cost-effective route to long-term care, allowing hospitals to spread the chronic care workload among a whole network of community-based health professionals, at a fraction of the cost.

Those benefits take on added urgency in an era of increasing cost pressures and the urgent push by Medicare, Medicaid and commercial payers to shift from a flat fee-for-service payment system to a new reimbursement model based on accountable care standards, successful patient outcomes and reduced hospital readmissions.

In October, that shift will gather steam when the Centers for Medicare and Medicaid Services launches a new pay-for-performance reimbursement system for all acute-care hospitals. The initial rollout of the Medicare Shared Savings Program will be limited, with hospitals facing a penalty of up to 1% of total payment for Medicare patients who are readmitted due to acute myocardial infarction, heart failure or pneumonia. But the reduction in payments for “substandard” care will rise to 2% in 2014 and 3% the following year, according to the Medicare Payment Advisory Commission. What’s more, CMS will add more disease states to the list of outcomes-based payment standards as time goes on.

“With health reform, … the focus is to keep the patient from being readmitted,” observed James Owen, senior director of professional practice for the American Pharmacists Association. “There’s a cost savings for that under these new payment models.”

The rise of evidence-based payments is one factor within the health-reform agenda spurring the creation of both hospital/community care partnerships and ACOs to improve continuity of care and cope with the new reimbursement paradigm. And it’s opening new bridges to patients and new revenue opportunities for participating pharmacies and retail clinics.

“With payers moving toward paying for quality … the only way to have solid quality is to protect the continuum of care,” urged Ken Berndt, CEO of Careworks Convenient Healthcare, the clinic division of Danville, Pa.-based Geisinger Health System. “If we’re going to get paid that way, you’ve got to have an ACO, and you have to have some retail for patient access.”

In Geisinger’s case, that reality led to a partnership with Weis Markets, a Pennsylvania-based supermarket and pharmacy chain. Geisinger operates and staffs Careworks clinics in three Weis stores in western Pennsylvania, and is adding 15 more centers in Weis outlets and other locations. “You’ve got to keep people out of the emergency room. It’s just too expensive, and there’s just not enough access without these,” Berndt said.

This year, MinuteClinic has allied with hospital systems in California, Florida, New Jersey and Tennessee. Under one agreement, doctors from the Florida Hospital Medical Group will serve as medical directors for 12 MinuteClinics in CVS stores in and around Orlando. The two providers also will collaborate on patient education and disease management initiatives.

More recently, MinuteClinic inked a pact in late July, under which physicians from UCLA Health System manage 11 of the clinics around Los Angeles, with clinicians referring walk-in patients to UCLA when necessary.

Walgreens’ retail clinic operation, Take Care Health Systems, also is allying with hospital groups around the United States, and bills itself as “the nation’s leading operator of hospital outpatient pharmacies, serving 137 health systems nationwide.” Walgreens also has partnered with major health centers, such as Johns Hopkins Medical Center, Ochener Health System, Louisiana State University, Valley Health System in southern Nevada and Northwestern Memorial Hospital. Through those arrangements, post-discharge patients directly transition to the care of a local Walgreens pharmacist or clinician “to enhance coordinate care” and develop better ways to track outcomes and care regimens, according to the company.

“One reason we’re working with hospital systems and universities is to have an independent opinion around some of the outcomes. The key is the outcomes,” explained Kermit Crawford, Walgreens’ president of pharmacy, health-and-wellness services and solutions. He said the partnerships are advancing the ACO model and teaching both sides how to better collaborate, document patients’ long-term progress and improve adherence. “We’re connecting with the physicians,” Crawford told DSN. “For example, at Northwestern, any conversations our pharmacists are having with the patient on adherence are being transmitted back to the physician at Northwestern.”

The experience also provides hospital-certified training for its pharmacists that Walgreens will “be able to scale across the entire organization,” according to Crawford.

Key to the success of such alliances is the ability of participating pharmacies and retail clinics to gather and electronically share accurate data on each patient in a health system’s records. “The whole notion of ambulatory pharmacy is a coordination of care — the integration of patient records, etc., that feed back into the hospital,” APhA’s Owen said.

Indeed, BI noted in a report on health technology, “some physicians remain skeptical that chronic care services can be provided in a retail setting. They express concern that important health factors may be missed because retail clinic practitioners often do not have a full medical history on their patients.”

That makes the use and sharing of electronic medical records a critical factor in the continuum of care. It’s about “fully integrating electronic medical record systems to streamline communication around all aspects of patients’ care,” according to MinuteClinic.

At the University of Wisconsin Hospital and Clinics, for instance, “all patients have an electronic medical record, and it’s allowed us to provide seamless care” that bridges the gap between the hospital and its network of allied pharmacies in the community around Madison, Wis., said Hannet Tibagwa Ambord, UW’s manager of oncology pharmacy and ambulatory pharmacy services.